This week, Texas Governor Greg Abbott halted all H-1B visa applications from state agencies and institutions until 2027. The H-1B is a high-skilled work visa that underpins American ingenuity and research in many STEM fields, and particularly health care. While it is important that high-skilled American workers get jobs in their chosen professions, such sweeping measures will only hamper scientific research in Texas and may further exacerbate the looming shortage of health care workers. Indeed, there is already an immigration bottleneck that prevents fully capable foreign-educated doctors from treating American patients who desperately need their care.
In a world full of doctors, the United States has a doctor shortage. Medical schools around the globe are graduating more physicians than ever. Across OECD countries alone, the annual number of new medical graduates has climbed from about 93,000 in 2000 to over 160,000 today. The United States remains one of the most attractive destinations to practice medicine, yet patients wait weeks for routine appointments, rural hospitals close their doors for lack of staff, all while many fully trained doctors already living in America are legally barred from treating patients.
Excellence at the top fails to trickle-down
In many respects, the United States has incredibly advanced health care. It leads the world in medical Nobel Prizes, is home to many of the most advanced hospitals on the planet, and delivers excellent outcomes for complex surgeries and certain cancers. At the same time, it ranks last among high‑income countries on basic health outcomes like life expectancy and preventable deaths, despite spending nearly twice as much per person on health care. In FREOPP’s World Index of Healthcare Innovation, the United States ranks first in scientific discoveries, but ranks last in public health care spending among countries included for the index.
The system’s failure becomes obvious when people try to see a doctor. If every American actually used the medical care that their medical conditions warrant, the country would be short more than 200,000 doctors today.
In rural communities, a specialist can be several hours drive away, and the physician workforce in those rural areas is projected to decline by nearly one quarter by 2030. Even in the largest 15 U.S. cities, the average wait time for an appointment is around 31 days, which means treatable conditions can become crises and lead to more invasive and expensive interventions.
The architecture of artificial scarcity
America did not simply “run out” of doctors. The shortage was not inevitable. The existing system keeps supply artificially low even as demand rises.
For example, in the Balanced Budget Act of 1997, Congress froze how many residency spots Medicare would help pay for at each teaching hospital, based on the number of residents that the hospital had in 1996. The goal was to save money, but this is the main way that residency training is funded. The money goes towards paying each resident a modest salary and supports teaching infrastructure. The cap was imposed during a perceived doctor surplus in the United States. Since then, the U.S. population has increased by almost 80 million people, while Congress has added just 1,000 Medicare-funded residency positions in 2021, spread over five years: a drop in the bucket compared with the population growth and projected shortages of up to 86,000 doctors by 2036.
A cap on residencies matters because a medical graduate cannot obtain specialty training or sit for board certification without completing a residency. The number of residency positions therefore directly determines how many people can become practicing physicians.
If residency capacity is the bottleneck, doctors from other countries should be able to fill the gap. Legally, however, the residency requirement still applies. A person who is a doctor in another country—no matter how long they have practiced medicine—cannot work in the United States without repeating a U.S. or Canadian residency. The residency cap thus limits both domestically and internationally trained doctors.
American visa policy does not help matters. Temporary work visas and the arduous path to permanent resident status are the two pathways that skilled immigrants use to work in the United States, and both have scope-of-work limitations. Physicians on work visas are often tied to a single employer or geographic area, making it difficult to move to the rural or understaffed regions where they are most needed. Meanwhile, long backlogs for U.S. green cards keep many doctors in limbo, unable to change jobs or expand their scope of practice even when community needs are obvious.
The case for international medical graduates
Given the scale of the shortage and the demographic wave ahead, a policy shift that actively incentivizes high-quality, foreign‑trained physicians to work in the United States will be crucial. More than one‑third of all active U.S. physicians will reach traditional retirement age within the next decade, and the population is both growing and aging; the number of Americans over 75 is projected to increase by about 55 percent between 2021 and 2036. Older patients need more and more specialized care—more cardiologists, oncologists, internists, surgeons—and they need it consistently. Advanced practice clinicians like nurse practitioners and physician associates are expanding access, but they cannot fully replace the depth and complexity of physician roles in many specialties.
Evidence also undercuts a common fear: that international medical graduates (IMGs) “take spots” or jobs from U.S. graduates. Research shows that the specialties with the fewest IMGs are precisely the most competitive for American graduates, combining high earning potential, lifestyle advantages, and prestige. Fields like dermatology, plastic surgery, neurosurgery, orthopedic surgery, and otolaryngology (ear, nose, and throat) are the most coveted residency positions and are overwhelmingly filled by U.S. graduates.
By contrast, IMGs are disproportionately represented in specialties that face persistent shortages and high community need. In the same analysis, IMGs make up substantial shares of the workforce in internal medicine (39 percent), neurology (31 percent), psychiatry (30 percent), and pediatrics (25 percent), all fields where access gaps are widespread and demand is projected to remain high. Internationally trained physicians are already doing the work that is hardest to fill, often in less glamorous specialties. Expanding their path to practice will not displace American doctors, but rather will reinforce them where the system is weakest.
The real shortage
The doctor shortage is a shortage of political will. The United States built one of the best systems for training individual doctors, while constructing one of the least efficient systems for letting them serve where and when they are needed.
There are commonsense policy changes that can be implemented right away, without waiting a decade for a new cohort of trainees to enter the workforce:
- Creating alternative pathways for international medical graduates to be able to practice medicine in the United States
- Creating faster, clearer pathways for doctors on temporary status to stay in the United States if they continue to practice medicine
- Allowing greater geographic and employer flexibility for those on work visas, so that they can work in high-need rural areas
Until policymakers align training capacity, immigration rules, and public health needs, the paradox will persist. In a world that produces more doctors than ever before, it is inexcuable that patients in the richest country on earth must keep struggling to find one.